The Growing Epidemic

Established 1911The American Journal of Public Health

September 1975, Vol. 65, No. 9

The Growing Epidemic

A Survey of Smoking Habits andAttitudes toward Smoking amongStudents in Grades 7 through 12 inToledo and Lucas County (Ohio)Public Schools-1964 and 1971

SAUL R. KELSON, MDJAMES L. PULLELLA, MPH

ANDERS OTTERLAND, MD, PhD

The increased smoking among boys and particularlygirls, in a recent 7-year period, is of epidemic

proportions. In combating this trend, the preceptsand examples of key adults, especially parents,

teachers, and physicians, are stressed, as well as theimportant role of the children's peers.

Introduction

The Northwestern Ohio Action on Smoking and Health(NO ASH) was funded by the Northwestern Ohio RegionalMedical Program in November, 1969. Besides stimulatingmore vigorous and innovative antismoking programsthroughout the region, working in cooperation withinteragency committees in the counties,' this project had as

Dr. Kelson, at the time of the first survey, wasChairman, Inter-Agency Committee on Smoking and Healthof Toledo and Lucas County, and at the time of the secondsurvey, Project Director, Northwestern Ohio Action onSmoking and Health. He is presently Chairman, OhioAdvisory Board on Smoking and Health, and is MedicalDirector, Toledo Health and Retiree Center, Toledo, Ohio43624. Mr. Pullella is Public Health Specialist, Northwest-ern Ohio Regional Medical Program. Dr. Otterland, for-merly Epidemiologist, Northwestern Ohio Regional MedicalProgram, is now Professor of Epidemiology, MeharryMedical College, Nashville, Tennessee. A third, similarsurvey is being conducted in 1975.

one of its goals to repeat for comparison a 1964 survey ofthe smoking habits and attitudes toward smoking of Toledoand Lucas County (Ohio) children. This study had beenperformed by the Inter-Agency Committee on Smoking andHealth of Toledo and Lucas County (Ohio). Data for thesecond survey were collected in the spring of 1971 bymeans of questionnaires distributed to and answered bystudents in the same grades and school districts as in 1964.Identical forms were used in 1971 as in 1964, with oneexception. In 1971 a question on the students' opinionsconcerning the influence of radio and TV programs on theirsmoking habits was added (Appendix A).

This paper reports the results of our analysis of datafrom 1964 and 1971.

Method ofData Collection and Analysis

Questionnaires were distributed to Toledo and LucasCounty public junior high and high schools. All students

THE GROWING EPiDEMIC 923

TABLE 1-Smoking Habits of Students in Grades 7 through 12 in Public Schools in Toledo and Lucas County 1964 and 1971 *

No. in Grade

7 8 9 10 1 1 12

Response and Year B G B G B G B G B G B G

Never smoked1964 107 164 75 114 53 116 53 103 49 61 36 56

1971 94 150 96 96 51 94 46 63 36 44 23 39

Tried to see what it was like, do not smoke1964 106 72 96 84 119 76 86 66 72 67 50 54

1971 129 126 111 117 92 92 68 87 50 72 45 48

Used to smoke 1 day a week but quit1964 19 7 20 9 21 6 19 5 13 10 8 6

1971 29 25 46 25 29 24 19 16 16 25 12 9

Smokes abbut 1 day a week1964 10 3 14 13 17 19 10 7 13 9 11 12

1971 39 17 22 40 22 41 15 25 16 15 8 15

Smokes every day less than 1/2 pack a day1964 9 6 7 8 19 4 31 9 28 17 20 19

1971 20 15 34 17 29 43 29 25 25 38 24 25

Smokes t/2 pack or more every day1964 5 1 10 2 12 4 21 7 15 12 25 6

1971 13 7 8 9 16 15 35 14 35 22 35 16

Size of sample1964 256 253 222 230 241 225 220 197 190 176 150 153

1971 324 340 317 304 239 309 212 230 178 216 147 152

* This table accounts for 1,234 females and 1,279 males in 1964, and 1,551 females and 1,417 males in 1971, which is a 10 per cent

sample of the total population interviewed. B, boys; G, girls.

present the day of the survey were asked to answer them intheir classrooms on time specifically set aside for thispurpose. The completed questionnaires were returnedunsigned.* Identical procedures in the same school districtswere used in 1964 and 1971.

In 1964, a total of 25,131 students (12,791 boys and12,340 girls) took part in the survey. In 1971, a total of29,682 students (14,169 boys and 15,513 girls) partici-pated.

A 10 per cent sample of the completed questionnairesfrom 1964 and 1971 is analyzed in this report.

A chi-square test was used to compare the ratios andthose mentioned here are significant at the 0.05 level.

parents' attitudes toward their (the children's) smoking(Question E).

The answers to Questions F, G, H, and K, concerningreasons for smoking or not smoking and the possibility ofgiving up smoking, however, gave insufficient data foranalysis because of high numbers of no response. Thisfailure to answer very likely occurred because Questions F,G, and H did not provide mutually exclusive alternatives.Two or more of the statements could well have expressedthe student's views. Rather than to "check one" asdirected, the student did not answer. The problem inQuestion K, "I could-could not-be persuaded to give upsmoking," may have been that the student just did not feelthat he or she could reply with any assurance.

Students' Smoking Habits, 1964 and 1971 tResults

Consistency of Data In Tables 1, 2, and 3 the smoking habits, in 1964 and1971, of students in the 10 per cent sample are presented.

No questionnaires had to be rejected because ofinconsistency. The questionnaires were filled out satisfac-torily for analysis of smoking habits among the students(Questions A, B, and I), their attitudes toward smoking(Questions D, J, and L), smoking habits of their parents(Question C), and for the students' perceptions of their

* An article indicates that, overall, anonymity made no

difference in responses by boys and girls to questionsconcerning smoking habits and attitudes.2

t Our study is concerned with the parameters ofsmoking of similar populations some 7 years later, and not,of course, of the same population after a lapse of time.Salber et al.3 have reported a survey according to the latterplan, of 560 boys and girls first studied in 1959 (with anaverage age, in grade 10, of 15.5) and studied again, 5-1/2years later, in 1965 (average age 21). The incidence ofsmoking almost doubled: in 1959, 35 per cent of the boysand 28 per cent of the girls were smokers, and in 1965, 63per cent of the boys and 55 per cent of the girls were

smokers.

924 AJPH SEPTEMBER, 1975, Vol. 65, No. 9

(Figure 1 gives some of this information in the form of agraph.) Grade by grade (Tables 1 and 2) the number ofsmokers* increased from 1964 to 1971, among both girlsand boys, but to a greater degree among girls. The increasein 1971 is greater among the ninth and eleventh grade girls.In 1964 less than one girl in 10 in grades 7 to 9 smoked; in1971, more than one in five smoked (Table 3)! For thetenth to twelfth grade girls, the number of smokers was lessthan one in five in 1964; in 1971 it was about one in three.It is significant that in the 1971 survey, the percentage ofgirl smokers was greater than that of boys in grades 8 and 9.

In 1964 the defined incidence of smoking among girlswas 59.0 per cent of that among boys. In 1971 it hadjumped to 85.7 per cent! If this steep increase continues weshall soon find as high an incidence of smoking among girlsas among boys.

From Table 1 we learn that in the 1964 study 373boys and 614 girls had never smoked (29.2 per cent of allthe boys and 49.8 per cent of all the girls). Thecorresponding figures for 1971 were 346 (24.4 per cent)and 486 (31.3 per cent). In 1964, 629 boys (49.1 per cent)and 462 girls (27.4 per cent) reported that they haddiscontinued smoking. In 1971, the corresponding figureswere 646 (45.6 per cent) and 666 (42.9 per cent). It isencouraging that many boys and girls do stop smoking, butthe increased numbers of those who continue constitute anepidemic.

Student Smoking: Three Cities, 4 years

Table 4 gives the percentages of smokers among ninthto twelfth grade boys and girls in Portland 1958,4 Toledo1964, Chicago 1967,8 and Toledo 1971.

The reader should keep in mind that all of the studieswere not based on the same questionnaire and technique ofdata collection. The table shows, in general, a trend to an

increased percentage of smokers in the successive surveys,

more marked among the girls, a rising gradient of smokersfrom lower to higher grades, and a preponderance of boyover girl smokers (with grade 9 of the 1971 Toledo survey

an exception).

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smoking, the term "smokers" must be defined. In variousstudies of smoking among children, its meanings havediffered considerably. In the Portland survey,4 that in

Dublin,0 and some others, a smoker is one who smokes one

or more cigarettes a week-the Dublin study stresses"regularly per week." In a 1959 British study,6 this isincreased to five or more cigarettes a week. In the Newton,Massachusetts, study,7 "A smoker was a student who hadsmoked at least ten cigarettes in the past and at the time ofthe questionnaire considered himself to be a smoker,regardless of the amount smoked." In the present paper, a

smoker is one who checked the first blank in Question I ofthe questionnaire: "At the present time I smoke-I do notsmoke-," unless scrutiny of the questionnaire, particularlyQuestion A, disclosed any inconsistency. In other words,the designation "smoker" is based on the student's own

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TABLE 3-Smoking Habits of Students in Grades 7 through 12 in Public Schools in Toledo and LucasCounty, 1964 and 1971 *

Grades 7-9 Grades 10-12 Total

Boys Girls Boys Girls Boys Girls

Nonsmokers1964 616 (85.7) 648 (91.5) 386 (68.9) 428 (81.4) 1,002 (78.3) 1,076 (87.2)1971 677 (76.9) 749 (78.6) 315 (58.6) 403 (67.4) 992 (70.0) 1,152 (74.3)

Smokers1964 103 (14.3) 60 (8.5) 174 (31.1) 98 (18.6) 277 (21.7) 158 (12.8)1971 203 (23.1) 204 (21.4) 222 (41.4) 195 (32.6) 425 (30.0) 399 (25.7)

Total1964 719 708 560 526 1,279 1,2341971 880 953 537 598 1,417 1,551

* Percentages are given in parentheses.

TOLEDO ANDSMOKING HABITS

LUCAS COUNTY PUBLIC SCHOOL STUDENTSGrades 7 thru 121964 and 1971

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FIGURE 1 Smoking habits of Toledo and Lucas County public school students, grades 7 to 12, 1964 and 1971.

Belief in Health Hazards of Smoking

The reasons why the students smoked were notlearned, as we have noted, if indeed the students themselvesknew why. Despite their smoking, the preponderance ofstudents, 2,256 of 2,513 (89.8 per cent) in 1964 and 2,705of 2,968 (91.1 per cent) in 1971 expressed the belief thatsmoking is harmful to health. Table 5 shows the smokinghabits of students who believed that smoking is a healthhazard and those who did not.

Relatively more smoking students in 1971 than in1964 indicated, despite their smoking, a belief that smoking

impairs health. We find more such students in the highergrades.

Smoking Habits of Parents

Table 6 shows the relative distribution of smokersamong the fathers and mothers of the Toledo area

schoolchildren surveyed in 1964 and 1971.It is noted that a smaller percentage of both parents

were smokers in 1971 than in 1964.Table 7 presents a more detailed analysis of smoking

by parents. An increase in nonsmokers from 1964 to 1971


is seen, both in the category, "Fathers only smoke," and in"Both parents smoke." The percentage rises in "Neitherparent smokes." In the category "Mothers only smoke,"however, the figure has increased, particularly for thesubgroup "Girls."

The smoking habits of the parents of students in grades7 to 9 and 10 to 12 are correlated with the smoking habitsof their children in Table 8. This table also gives thenumbers, in 1964 and 1971, of smoking and nonsmokingchildren and the percentage of nonsmokers in eachsubgroup. The highest figures for smokers among childrenare found when both parents smoke, except among girls ingrades 10 to 12 in 1964. When neither parent smokes, thepercentage of smokers among the children is significantly

TABLE 4-Comparison of Smoking Incidence among Ninth toTwelfth Grade School Children in Portland, 1958;Chicago, 1967; and Toledo, 1964 and 1971

Portland4 Toledo Chicago' ToledoGrade 1958 1964 1967 1971

Boys9 18 18 22 2710 30 28 32 341 1 36 29 40 3912 40 37 42 45

Girls9 6 11 22 2910 13 11 28 2511 20 21 3 1 351 2 31 24 28 38

smaller than if the father or mother or both are smokers,except among girls in grades 7 to 9 in 1964.

How the Children Think Their Parents Stand on TheirSmoking or Not Smoking

The children's perception of parents' attitudes towardtheir smoking or not smoking is correlated in Table 9 withsmoking or nonsmoking by children in grades 7 to 9 andgrades 10 to 12 for the years 1964 and 1971.

We find relatively higher numbers of children whosmoke when both mother and father approve, when thechildren feel that neither parent cares, and when theparents disagree about the child's smoking. The smallestrelative number of smokers is found in the group in whichboth father and mother do not allow the child to smoke.Slightly more smokers are found when both parents areagainst their child's smoking, but have not clearly prohib-ited it. This is true for both 1964 and 1971.

Table 10 shows the parents' attitudes, as stated bytheir children, toward the children's smoking. Here,smoking and nonsmoking students are not grouped separ-ately. Parents were seen as more tolerant of their children'ssmoking in 1971 as compared with 1964. This appears fromtheir more frequent approval of smoking in 1971, their lessfrequent disapproval, and their not revealing to theirchildren their feelings in the matter. The differences arestatistically significant. This parental tolerance is moreapparent toward the older children and especially towardthe boys. "Both mother and father are against child'ssmoking," however, appears, rather surprisingly, to a

TABLE 5-Smoking Habits and Belief That Smoking is Harmful to Health among Students in Grades 7 to.9 and 10 to 12 in Toledo and Lucas County Public Schools, 1964 and 1971 *

Grades 7-9 Grades 10-12

1964 1971 1964 1971

Believed smoking is harmful to healthSmokers

Boys 72 (10.9) 164 (20.4) 122 (25.5) 182 (37.7)Girls 44 (6.8) 169 (19.3) 77 (16.3) 168 (30.9)

NonsmokersBoys 587 (89.1) 639 (79.6) 357 (74.5) 301 (62.3)Girls 602 (93.2) 706 (80.7) 395 (83.7) 376 (69.1)

Subtotal 1,305 1,678 951 1,027

Did not state smoking harmful to healthSmokers

Boys 31 (51.7) 39 (50.6) 52 (64.2) 40 (74.1)Girls 16 (25.8) 35 (44.9) 21 (38.9) 27 (50.0)

NonsmokersBoys 29 (49.3) 38 (49 4) 29 (35.8) 14 (25.9)Girls 46 (74.2) 43 (55.1) 33 (61.1) 27 (50.0)

Subtotal 122 155 135 108

Total 1,427 1,833 1,086 1,135

* Percentages are given in parentheses. In 1964 2,256 of 2,513 (89.8 per cent) believed smoking isharmful to health. In 1971 2,705 of 2,968 (91.1 per cent) believed smoking is harmful to health.


TABLE 6-Smoking by Parents*

1964 1971

Fathers 66.3 45.6Mothers 44.6 35.9

* Percentage of smokers among all parents of the same sex inthe series.

greater extent, for girls in grades 10 to 12 than in grades 7to 9, both in 1964 and 1971.

Smoking in Front of Parents

Even as early as the seventh and eighth gradesyoungsters smoke in front of their parents (Table 11).

The percentage of students who smoke in front of theirparents increases by grade. The boys do so earlier than dogirls. Girls hide their smoking from their parents to agreater degree all through the school years.

Opinions of the Influence of TV Presentations on theStudents' Smoking Habits

Questions concerning the students' opinions as to theinfluence on them of radio and TV presentations, bothpromoting and opposing the use of cigarettes, appearedonly on the 1971 questionnaire (Appendix A).

In Table 12 we find that 93 boys and 97 girls believedthat the net effect of radio and TV programs, spots, andcommercials had been to influence them in favor ofsmoking. These were predominantly seventh to ninthgraders. Both smokers (constituting about 60 per cent ofthose who expressed such an opinion) and nonsmokers gavethis answer. All of these nonsmokers previously hadsmoked and then quit.

Many students, 1,105 of them (512 boys, 593 girls),noted that radio and TV presentations had influenced themagainst smoking. Six hundred eighty (320 boys, 360 girls)of this number were in grades 7 to 9. About 10 per cent ofthe seventh to ninth graders and 25 per cent of the tenth totwelfth graders who gave this opinion were, however, stillsmokers. Fifty-six boys and 42 girls in all grades who saidthey had been influenced against smoking had quit.

A total of 1,673 students believed that TV programsand commercials had not influenced them in eitherdirection. For smokers, both boys and girls, in grades 7 to 9and grades 10 to 12 as well, this was by far thepredominant answer.

Other Studies

Smoking among Adults

Many surveys on smoking habits and smokers' andnonsmokers' attitudes toward smoking have been per-formed over the years. Among them, Characteristics of

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Smokers and Nonsmokers in Tecumseh, Michigan9 byPayne et al. is of particular interest since it describes thesmoking habits in 1959-1960 of a population in acommunity adjacent to Northwestem Ohio (Table 13).

Sixty per cent of all men and 34 per cent of all womenin Tecumseh were cigarette smokers in 1959-1960. Therewere more smokers, both among men and women, in theage group 30 to 49 than earlier and later in life. Amongteenagers (16 to 19) 41 per cent of the boys and 22 percent of the girls smoked.

Figures for 5 years later were published by the U.S.Department of Health, Education, and Welfare in its ChartBook on Smoking, Tobacco and Health. 10 A 1965 nationalsurvey found 51 per cent of men and 34.7 per cent ofwomen to be smokers, and 19 per cent of men and 8 percent of women ex-smokers (Figure 2).

From the National Conference on Smoking and Healthof 1970 we obtain a 4-year comparison of smoking habitsin the United States' 1 (Table 14).

Among both men and women a lower percentage ofsmokers was found in 1970 than in 1966: 51.9 per cent ofmen and 33.7 per cent of women smoked in 1966, in 1970these percentages were 42.0 and 31.0, respectively. In1971, however, the U.S. Department of Agriculturereported that the per capita cigarette consumption reversedits 4-year downward trend and rose by 2 per cent over 1970to 202 packs per American age 18 or over.' 2

Smoking among Schoolchildren

Horn and colleagues,4 surveying Portland, Oregon, highschool students in 1958, found 30 per cent of the boys,ranging from 18 per cent in grade 9 to 40 per cent in grade12, and 17 per cent of the girls, ranging from 6 per cent ingrade 9 to 31 per cent in grade 12, to be smokers (Table 4).

Ten years later, in 1968, the National Clearinghousefor Smoking and Health commissioned a survey conductedby telephone of 4,414 boys and girls from ages 12 through18 (approximately 315 of each sex at each age.)'13 Thepercentage of smokers ranged from 1.3 of boys and 0.3 ofgirls at age 12 to 35.5 of boys and 21.3 of girls at age 18with an overall percentage of 14.7 of boys and 8.4 of girls.

Repeated 2 years later, with approximately 185telephone interviews of each sex and age, the surveyshowed that "teenage smoking increased for both sexes andat every age level." "Current regular smokers" among boysrose from 14.7 per cent of 1968 to 18.5 per cent, andamong girls from 8.4 per cent to 11.9 per cent. For girlsages 15 to 16 the 1968 rate of 9.7 per cent rose to 14.4 percent in 1970; the increase for boys was small. The greatestabsolute increase took place among boys of 17 and18-from 30.2 per cent in 1968 to 37.3 per cent in 1970.

In 1959, Salber et al.7 surveyed 3,449 boys and 3,361girls in grades 7 to 12 in Newton, Massachusetts. Thissurvey found that 26.7 per cent of all boys, ranging from6.8 per cent in grade 7 to 45.6 per cent in grade 11, were

smokers. Of the girls, 21.2 per cent were smokers: theranges were from 1.1 per cent in grade 7 to 54.7 per cent in


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grade 12. The preponderance of boy over girl smokersdiminished in successive grades until the percentage of girlsmokers in grade 12 exceeded that of boys (54.7 per centto 45.5 per cent).

In 1967, the American Cancer Society, Chicago Unit,studied smoking in the Chicago public schools,8 withresponses from 222,560 students in grades 4 to 12. Ingrades 9 to 12 it reported a 34 per cent incidence ofsmoking among the boys and 27 per cent among the girls.There was more smoking among both the boys and girls inChicago than in Portland and significantly more among thegirls (Table 4).

Much lower percentages were found in a 1965 surveyby Palmer' 4 of 3,112 junior high school students in ruralSouth Dakota and Iowa. Among boys in grades 7, 8, and 9the percentages of smokers were 6.5, 6.1, and 12.3,respectively, and among girls 0.6, 2.2, and 3.3.

"Rural" appears to be the key to this favorable finding.As the Chart Book on Smoking, Tobacco, and Health'0reported, based on a 1965 survey, "Fewer people who liveon farms smoke than those who live in metropolitan areas.The difference is particularly striking among women; onlyabout 16 per cent of the women who live on farms smoke,contrasted with 36 per cent of the women who live inmetropolitan areas. Among men, the comparable figures are45 and 51 per cent." The surveys from the NationalClearinghouse'3 showed that "Girls living in metropolitanareas are more likely to,smoke than those in non-metropol-itan areas." For boys, "this difference is not statisticallysignificant...."

Perception of Health Dangers of Smoking

What do schoolchildren believe about the hazards tohealth from cigarette smoking? Of the 8,272 Cincinnatiseventh and eighth graders whom Streit' 5 studied in 1966,98 per cent said they knew smoking contributed to lungcancer and chronic lung disease; and 65 per cent believed itcontributed to heart disease and hardening of the arteries.Did this knowledge influence them not to smoke?Approximately 75 per cent answered that it did.

In both National Clearinghouse surveys' 3 (1968 and1970) of teenage smoking, the great majority of school-children agreed that smoking is harmful to health.Answering "Yes," "No," and "Don't know," respectively,were 92.0 per cent, 4.0 per cent, and 4.0 per cent of allboys; 93.1 per cent, 3.7 per cent, and 3.2 per cent of allgirls.

A national study of 1,562 teenagers conducted in 1969for the American Cancer Society by Lieberman Research,Inc.,'6 reported that 65 per cent of smokers and 86 percent of nonsmokers believed that cigarette smoking is acause of cancer, and 52 per cent of smokers and 71 per centof nonsmokers replied that it was "definitely or probablytrue" that smoking triples the chance of a heart attack.

Since schoolchildren have such a strong belief in theharmful effects of smoking, why is smoking so prevalent?Very likely, because the threats seem so far in the future.

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TABLE 11-Do Students Smoke in Front of Their Parents?*

No. in Grade

7 8 9 10 11 12

Response and Year B G B G B G B G B G B G Total

Smoke in frontof parents1964 1 1 2 1 1 5 22 7 44 15 38 26 54 22 257

1971 20 8 12 9 29 27 47 26 49 34 49 31 341

* B, boys; G, girls.

TABLE 12-Have Radio and TV Programs and Commercials Influenced theabout Smoking? (1971 )*

Students' Ideas

Boys Girls

Response Grade S NS S NS

Believe that radio and 7-9 40 28 39 45

TV programs and commercialshave influenced him or her 10-12 18 7 7 6

in favor of smokingBelieve that radio and 7-9 33 287 37 323

TV programs and commercialshave influenced him or her 10-12 45 147 47 186

against smokingDoes not believe that radio 7-9 33 362 128 381

and TV programs and commercials (26.4) (25.1)have influenced him or hereither way 10-12 159 161 141 211

(49.7) (40.1)

* Percentages in this table (in parentheses) are derived by comparingsmokers to the population in that subgroup. S, smokers; NS, nonsmokers.

the number of

Children's Smoking Habits as Relatedto Their Parents'

In 1961 Salber and MacMahon,'7 studying 2,823 highschool students, found 51 per cent of the boys and 13 percent of the girls to be smokers when both parents smoked,and 25 per cent of the boys and 4 per cent of the girls to besmokers when neither parent smoked. When only one

parent smoked the percentages fell between those of theother two categories. The incidence of smoking by thechild, whether boy or girl, did not appear to be related,when only one parent smoked, to the smoker's being thefather or the mother.

In a study of 251 undergraduate men and women andtheir parents, Wohlford'8 found that the smoking behaviorof the sons was directly related to that of their fathers inintact families. "The mother and daughter smokingpatterns," however, "remained enigmatic."

Studying 3,112 rural junior high school students in1965, Palmer'4 found only four instances of boys smokingregularly whose fathers were nonsmokers, and none whose

parents were both nonsmokers. Of boys who smoked, 53.9per cent reported both parents as smokers; for girls whosmoked, the figure was 58.9 per cent.

The survey of Liebernan Research, Inc.,'6 reportedparental smoking as a determinant of the children'ssmoking but following in importance smoking by friendsand then older siblings. Parental smoking, it was found, was

less significant than rapport with parents in determiningwhether the child smoked. "A teenager is less apt to smokeif he has good rapport with his parents and they smokethan if his parents don't smoke, but he has bad rapportwith them." (Similarly, bad rapport with parents has beenstressed as a major determinant in the use of marijuana byteenagers.' 9 )

Parents' Attitudes toward Children's Smoking

So much for the parents' examples. What of theirprecepts? There have been a number of studies of theattitudes of parents toward their child's smoking, as well as

what the child perceives the parents' attitudes to be. Of the


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Cincinnati pupils Streit' s studied, only 15 per cent saidthat their parents approved of their smoking; 23 per centsaid they didn't know what their parents thought.

In 1968, Clausen20 reported from his Oakland,California, study that "almost no parents" approved theteenager's smoking. Fewer than one-fifth did not mindwhether their teenage children smoked. Definite objectionsby parents, he found, were much more frequent to smokingby daughters than by sons.

In his South Dakota and Iowa study, Palmer' 4 askedjunior high school students to tell whether their parentsapproved or would approve of their smoking. Of nonsmok-ing boys 0.5 per cent indicated such approval, 97.0 per centdisapproval; 1.3 per cent of nonsmoking girls indicatedapproval, 97.1 per cent disapproval. For boys who smokedregularly the corresponding figures were 16.2 per cent and81.0 per cent; and for girls smoking regularly, 25.8 per centand 74.1 per cent.

An interesting turnabout: Lieberman Research, Inc.,' 6asked teenagers over the nation how they would feel abouttheir own children smoking. Eighty-six per cent felt thatthey would disapprove.

Smoking in the Presence of Parents

In a study of New Zealand high school students,Newman et al.2 1 reported in 1970 the percentages ofsmokers who smoked in the presence of either parent. Forboys this ranged from 15.1 per cent in the first year up to36.5 per cent in the third; for girls, from 20.5 per cent inthe first year to 55.9 per cent in the fourth.

Effects of Radio and TV Presentations

What of young people's opinions of the influence ofradio and television programs, commercials, and spotsabout smoking? The Lieberman survey' 6 stated, "In thefirst four weeks, teenagers report seeing or hearing anaverage of 8.9 anti-cigarette spots, compared with 30.5pro-cigarette spots. Thus, teenagers are getting exposed toboth sides of the issue, but they are seeing or hearing morethan three times as many spots supporting the cigarettehabit as they see or hear attacking the habit.

"Interestingly, the actual pro-to-anti ratio is probablyabout six to one, while according to teenagers' recall theratio is closer to three to one. This suggests that theanti-cigarette spots are getting through to and are penetrat-ing teenagers' minds with greater impact than their sheerfrequency would warrant, relative to pro-cigarette spots onthe air."

O'Keefe22 reported in 1971 a survey of Florida2,, students and adults. Nearly 70 per cent of the nonsmokers

and 52.3 per cent of the smokers thought the antismokingmessages were effective. Of the students who smoked, 34

E per cent said the messages had led them to smoke less.° Similarly, 34 per cent said that they thought more about* the ill effects of smoking than before, and 22 per cent said

the spots had influenced them to stop smoking temporarily.Many people had looked forward to the end of


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FIGURE 2 Characteristics of present smokers.'

cigarette commercials on January 1, 1971, as leading to a

decrease in smoking. When cigarette sales rose sharply in1971, some, including the Department of Agriculture,attributed the rise chiefly to the falling off of antismokingmessages that had been required to be broadcast under theFederal Communications Commission's "equal time" regu-

lation. A Justice Department official even suggested thatCongress might serve the nation's health better by repealingthe ban on cigarette advertising to force equal time forantismoking messages.2 3

Discussion

Smoking by parents, as reported by their children, fellsharply among mothers as well as fathers during the timebetween our two surveys (1964 and 1971). The decline insmoking among women runs counter to the nationaltrend.24 We do not know why it occurred in and aboutToledo in the face of an upturn over the country.

But the striking and discouraging finding of our surveys

is the steep rise in smoking by children, particularly the

girls-fast catching up with the boys (and actuallyovertaking them in grades 8 and 9 in 1971). This prevalenceof smoking among the young constitutes an epidemic-agrowing epidemic. In 1971 fewer girls belonged to the"never smoked" group than in 1964. Fewer boys discon-

tinued smoking in 1971. Relatively more of the girls did

stop after having started, but not enough to prevent an

overall increase among them.We cannot say that our efforts have failed entirely, for

without them, very possibly the climb in smoking amongschoolchildren would have been even more pronounced.But, as Godber25 says of the campaign against "smokingdiseases" in his native England, "the successes we have

achieved. . . are pitifully small."

What can be done? Horn's26 advice is sound: ".. . onemust work to reduce both adult and teenage smokingsimultaneously and with equally vigorous efforts, since theystrongly influence each other."

Education to the health hazards of smoking is notenough, as our findings, and those of others cited, show. Ahigh percentage of youngsters believe that cigarettesmoking can cause lung cancer, emphysema, heart disease,etc.-and still they smoke. Michelson2 7 states, "The youngperson is not deterred from smoking by fears or threatsregarding illness or death," but he adds that children are"concerned about the possibility of illness and death oftheir parents."* How often have we encountered a fatherwho stopped smoking after his child repeatedly cautioned,"Better put it out, Dad. You'll get cancer!"

A new approach is needed. The present trend to starteducation in earlier years seems highly desirable. The NewYork State Curriculum Guide2 8 recommends that teachingabout smoking and health begin in the fourth grade. Alongwith the emphasis on the hazards to health, there must be,as the Dublin study5 stresses, effort "to give students anorientation towards positive health habits so that theyrealize they have a duty to develop and maintain theirpotentiality for physical and mental well-being."

The results of innovative educational approaches, suchas the campaign of the American Cancer Society based onthe work of the Creative Advertising Workshop at theUniversity of Michigan, will bear watching.29 This rejectscommon approaches directed at adult, addicted smokers; itrejects, too, scare techniques and preaching. Among otherways, it attempts "to reach teenagers by recognizing theirability to see through phoney approaches and appreciatewell-directed satire and sarcasm." It "identifies teenagenon-smokers as beautiful people, people in love, happypeople doing ordinary things"-an atmosphere in whichcigarettes are incongruous. It points out to the teenager"the absurdity of cigarettes and of the smoking habit." Itstresses the generation gap: smoking is an old-fashionedpractice belonging to the older generation.

Another innovation is the Berkeley Project30 directedby Richard L. Foster, EdD, which attempts to teachchildren, especially those in grades 5, 6, and 7, "a belief intheir body as a beautiful system. And that no one shouldabuse that system by smoking, drugs, or anything elsedamaging."

More important than any organized educational at-tempts to influence the young, we believe, are redoubledefforts, on a person-to-person basis, of the various groups ofkey adults most able to change young people's behavior.

* Withdrawal clinics, even if feasible on a large scale,appear to be no answer to children's smoking, inMichelson's experience,2 in which 35 students signed upfor a clinic at a Maryland high school in 1964. Thoseattending gradually decreased, until only two remained inthe last session. Just one child had stopped smoking then,and "probably has resumed." Similarly, Salber et al.3report withdrawal clinics for teachers as unsuccessful. As inother approaches to smoking control, some may wellsucceed here where others have failed. Something can belearned from both successes and failures.


Who Smokes Cigarettes?

MALE

(Population = 57,585,000)

Quoting Salber,3' "The demonstration of the extent towhich the fate of their children lies in adult hands mayconvince adults to take preventive action they might not bewilling to take for their own benefit."

One such group of adults certainly is the parents. Ourstudy indicates how important their examples and preceptsare on their children. Their greater permissiveness appearsto be a significant factor in the upturn of smoking, as in therelated surge of drug abuse and alcohol use.* Rapport ofparent with child is a central factor in stemming all three,but this is more easily prescribed than accomplished.

The role of the teacher in influencing children not tostart smoking or to give it up can be great, but the poorexample of a teacher's being seen-or even known-tosmoke can undo all his effectiveness. Such a view is widelyexpressed. Leedham3 2 says, "A convinced, dedicatedteacher can, in so many ways, build up the favorable imageof the non-smoker. But for this task the teacher must be anon-smoker, since by example alone can he or she impartconviction.... To the young mind, insincerity can bedevastating...." And Hamburg33 states, "Students whofeel that school personnel really care about whether theystart to smoke or not are probably less apt to start. Ateacher's concern for the well-being of the students, if it issincere and not a moral judgement, probably has moreeffect on young people than is appreciated." " 'Do as I say,not as I do' does not have much educational power. Andneither does 'I wish I had never started,' or 'If I had knownwhen I was your age.' "

For this role in influencing students both by persuasionand example, the teacher must be kept informed of thefacts of smoking and health. Antismoking groups in thecommunity can help sustain his or her motivation; theparent-teacher groups should have an important place inthis effort.

The Lieberman survey16 reported that "young peoplemight resist beginning the cigarette habit, or could moreeasily stop it, if figures of authority and influence such asteachers and physicians set better examples and urged themnot to smoke." Physicians have set an excellent example,having given up smoking in great numbers. As the wellknown poster attests, "100,000 Doctors Have Quit Smok-ing." But all too often physicians do not speak outemphatically to their patients. "The trouble with doctors,"it has been said, "is that they don't preach what theypractice!" Of the nonsmokers among teenagers surveyed byLieberman Associates, Inc.,1 6 72 per cent said physicianswere the one group that could persuade them not to startsmoking; of the smokers, 42 per cent said that advice froma physician would influence them to stop.

General practitioners, internists-in fact, all physi-cians-can contribute greatly to the antismoking effort.This is especially true fQr qb5tet1icians apd pediatriciariObstetricians have a key role in ministering to two livessince when mothers smoke there is strong evidence of an

* A reasonable but undocumented theory is thatparents these days may ignore their children's cigarettesmoking, being so thankful that they are not usingmarijuana and heroin.

TABLE 14-A 4-Year Comparison of Smoking Habits in the UnitedStates*

Men Women

1966 1970 1966 1970

% who had ever smoked 75.5 75.3 43.2 45.8% of these continued smoking 68.7 55.7 78.0 66.4% of all men or women smoked 51.9 42.0 33.7 31.0% who smoked 30+ cigarettes/day 29.2 27.0 15.5 14.5

* From Streit.' '

increased incidence of spontaneous abortions, stillbirths,and infant deaths in the first month of life.34 Pediatriciansplay a vital part in influencing the child against taking upthe smoking habit and in protecting the respiratory tract ofthe infant against the now recognized ill effects of smokefrom the mother's cigarette-perhaps the most emphaticexample of "the rights of the nonsmoker." Pointing out theharm she does to her small child can be a very effectiveinducement to a woman to stop smoking.

To these three adult groups three others are added-thedentist, nurse, and athletic coach. With growing knowledgeof the harm that cigarette smoking does to the teeth andgums, the dentist has a strong stake in antismoking; manydentists have done vigorous and effective work with theirpatients.

The nurse is in a strategic position to influence peopleagainst smoking in the physician's office, in the hospitaland clinic, in the school, and in industry, but the success ofantismoking pressure on the nurse herself so far has notappeared impressive.

The athletic coach, among the first of antismokingadvocates, from his early first hand observations of thedeleterious effects of "coffin nails" on athletic perform-ance, can do great good. With the possible exception ofhealth educators, no group is so convinced of the harmcigarettes do as are athletic coaches. Morris and Tichy35found that 99 per cent of the athletic coaches surveyed inOregon in 1970 believed smoking harmful to health. In asimilar survey3 6 conducted in the Toledo area in 1969, 99per cent of the coaches expressed this same belief. (Theirpractices coincided well with their belief: 80 per cent saidthey smoked no cigarettes at all. Only 6 per cent reportedsmoking more than one pack a day.)

To these adult person-to-person persuaders we shouldadd another group, found in a national survey' 6 to be firstamong the determinants of a teenager's smoking. These arethe peers, the child's friends and associates. Were it possibleto mobilize leaders of the peer group as an antismokingf(rca, they cqUld become e6 effeptive fQr lQod s they Maybe for ill.i

What can be accomplished when a highly organizedantismoking effort, involving forces from the wholecommunity and having federal support, vigorously takes upbattle against cigarettes, using measures such as we havenoted? Such a community is San Diego, California, and the


TABLE 15-Incidence of Smoking among Students, San Diego,1967 and 1971

Boys Girls

G rade 1967 1971 1967 1971

7 16.9 9.5 10.0 12.28 17.5 13.5 11 19.29 25.2 16.8 18.5 22.0

1 0 31.8 19.7 20.6 22.81 1 32.7 24.7 31.1 25.41 2 34.7 28.8 29.3 25.3

figures in Table 15 indicate the incidence of smokingamong boys and girls in grades 7 through 12 in 1967 and1971.3 7 The reduction seen in the boys' smoking isimpressive (when Toledo area boys were smoking more),but, except in the eleventh and twelfth grades, smokingamong girls had increased.

It is evident that we must redouble our efforts in thebest ways we know how against "the greatest preventablecause of illness, disability and premature death in thiscountry."38 Some day, no doubt, there will be betterarmaments-"safe cigarettes" perhaps; some effective medi-cation; some totally unexpected breakthrough.*

ACKNOWLEDGMENTS

We acknowledge the financial support and staffparticipation of the Northwestern Ohio Regional MedicalProgram and of the Inter-Agency Committee on Smokingand Health of Toledo and Lucas County. We thank theToledo and Lucas County schools and the Toledo andLucas County Health Departments for their cooperation inmaking these surveys possible. To the following we expressparticular gratitude: Mr. 'James Felkey, Miss MagdaHinojosa, Mr. Richard Honner, Mr. William Jacob, Mr.George Nimmo, Mr. C. H. John Padrutt, Mrs. CharlotteRichards, Martin Welch, MD, and William Wiersma, Jr.,EdD.

References

1. Kelson S. R. Developing Interagency Committees toCombat Smoking. Ohio's Health 23:19-21, 1971.

2. Harlin, V. K. The Influence of Obvious Anonymity onthe Response of School Children to a Questionnaireabout Smoking. Am. J. Public Health 62:566-574,1972.

3. Salber, E. J., Freeman, H. E., and Abelin, T. NeededResearch on Smoking: Lessons from the NewtonStudy. In Smoking Health and Behavior, edited byBorgatta, E. F., and Evans, R. R. Aldine PublishingCompany, Chicago, 1968.

4. Horn, D., Courts, F. A., Taylor, R. W., and Soloman,E. S. Cigarette Smoking among High School Students.Am. J. Public Health 49:1497-1511, 1959.

* Even now there is one measure of perhaps explosivepotential, especially in the less inhibited climate of today'ssociety, against smoking among adults and older children-making known the adverse effects of smoking on sexualfunctioning, as indicated by Ochsner.3

5. O'Rourke, A., and Wilson-Davis, K. Smoking andSchool Children. J. R. Coll. Gen. Pract. 20:354-360,1970.

6. Chave, S. P. W., and Schilling, R. S. Smoking Habits ofSchool Children. Br. J. Prev. Soc. Med. 13:1-4,1959.

7. Salber, E. J., Goldman, E., Buka, M., and Welsh, B.Smoking Habits of High-School Students in Newton,Massachusetts. N. Engl. J. Med. 265:969-974, 1961.

8. American Cancer Society, Chicago Unit. Survey onStudent Smoking Habits in the Chicago Public Schools.1967.

9. Payne, M., Kjelsberg, M. O., and Metzner, H. Character-istics of Smokers and Nonsmokers in Tecumseh,Michigan. I. Progress Report from the Department ofEpidemiology. University of Michigan, Ann Arbor,1969.

10. Chart Book on Smoking, Tobacco, and Health. P.H.S.Publ. No. 1937. U.S. Department of Health, Educa-tion, and Welfare, Washington, DC, 1969.

11. Streit, W. K. Report from the National Conference.Ohio's Health 23:16-18, 1971.

12. Miller, R. H. U.S. Department of Agriculture Report.Presented at 50th National Agriculture Outlook Con-ference, Feb. 23, 1972.

13. National Clearinghouse for Smoking and Health.Teenage Smoking, National Patterns of CigaretteSmoking, Ages 12 through 18, in 1968 and 1970.DHEW Publ. No. (HSM) 72-7508. Health Services andMental Health Administration, Regional Medical Pro-grams Services, Washington, DC, 1971.

14. Palmer, A. B. Some Variables Contributing to theOnset of Cigarette Smoking among Junior High SchoolStudents. Soc. Sci. Med. 4:359-366, 1970.

15. Streit, W. K. Students Express Views on Smoking. J.Sch. Health 37:151-152, 1967.

16. Teenage Smoking, New ACS Study Shows YoungPeople's Beliefs and Behavior. Cancer News 23:3-7,1969-1970.

17. Salber, E. J., and MacMahon, B. Cigarette Smokingamong High School Students Related to Social Classand Parental Smoking Habits. Am. J. Public Health 51:1780-1789, 1961.

18. Wohlford, P. Initiation of Cigarette Smoking: Is ItRelated to Parental Smoking Behavior? J. Consult.Clin. Psychol. 34:148-151, 1970.

19. Burt, J. J., and Brunner, J. A. Feeling toward ParentsMay Play Major Role in Teen Drug Abuse. Alumnus,University of Toledo 18:11-14, 1971.

20. Clausen, J. A. Adolescents Antecedents of CigaretteSmoking: Data from the Oakland Growth Study. Soc.Sci. Med. 1:357-382, 1968.

21. Newman, I. M., Ang, J., Irwin, R. P., and Smith, J. M.Adolescent Cigarette Smoking. N. Z. Med. J.72:161-166, 1970.

22. O'Keefe, M. T. The Anti-smoking Commercial: AStudy of Television's Impact on Behavior. PublicOpinion Q. 35:242-248, 1971.

23. Wilson, B. C. Deputy Assistant Attorney General.Quoted in New York Times, Feb. 13, 1972.

24. Steinfeld, J. L. Cigarette Smoking Is on the Increaseamong Women-and They Also Find It Harder to Quit.Bull. Natl. Tuberc. Respir. Dis. Assoc. 57:1-5, 1971.

25. Godber, G. E. Smoking Disease: a Self-Inflicted Injury.Am. J. Public Health 60:235-242, 1970.

26. Horn, D. Current Smoking among Teenagers. PublicHealth Rep. 83:458-460, 1968.

27. Michelson, E. Adolescent Smoking Withdrawal Clinic.J. Sch. Health 36:364-367, 1966.

28. State Education Department, Curriculum DevelopmentCenter, Health Curriculum Materials. Strand IL Socio-logical Health Problems. University of the State of NewYork, Albany, 1967.


29. American Cancer Society presentation. University ofMichigan, Creative Advertising Workshop (mimeo-graphed).

30. Foster, R. L. These Fifth Graders Are Excited aboutHow Their Lungs Work; This Is the Berkeley Project, aNew, Revolutionary Approach to Health Education.Bull. Natl. Tuberc. Respir. Dis. Assoc. 57:4-9, 1971.

31. Salber, E. J. Smoking among Teen-Agers. Bull. N. Y.Acad. Med. 44:1521-1525, 1968.

32. Leedham, C. L. Pre-Teen Smokers. Clin. Pediatr.(Phila.) 6:135-136, 1967.

33. Hamburg, M. V. What Can the Schools Do? Bull. N. Y.Acad. Med. 44:1526-1535, 1968.

34. The Health Consequences of Smoking. A Report to theSurgeon General, Ch. 5, Pregnancy, pp. 387,-418.DHEW Publ. No. (HSM) 71-7513. U.S. Department of

Health, Education, and Welfare, Washington, DC,1971.

35. Morris, J. F., and Tichy, M. W. Smoking Habits andAttitudes of Oregon Secondary School Coaches. Am. J.Public Health 60:1271, 1970.

36. Survey of Smoking Habits and Attitudes, High SchoolAthletic Coaches of Lucas County. Conducted byInter-Agency Committee on Smoking and Health ofToledo and Lucas County (Ohio), 1969.

37. Smoking research, San Diego.38. Stewart, W. H., Former Surgeon General, U.S. Public

Health Service. Cited in Diehl, H. Tobacco and YourHealth, p. 1. McGraw-Hill, New York, 1969.

39. Ochsner, A. Influence of Smoking on Sexuality andPregnancy. Med. Aspects Hum. Sexual. 5:78-92,1971.

APPENDIX A

SMOKING HABITS AND ATTITUDES SURVEY

INTERAGENCY COMMITTEE ON SMOKING AND HEALTH OF TOLEDO AND LUCAS COUNTY

NORTHWESTERN OHIO ACTION ON SMOKING AND HEALTH

a hool Identificationhw)l Grade 6-7-8-9-10-11-12-SP.ED. (Circle one) Age Sex: Male Female_

A. CHF.CK ONE STAT-EMENT (and only one) THAT BEST DESCRIBES YOUR SMOKING HABITS AT PRESENT.

1. ( ) I have NEVER SMOKED.2. ( ) I have tried smoking but ONLY to see what it is like. I do not smoke at present.3. ( ) I used to smoke at least one day a week, but I quit.4. ( ) I do not smoke every day, but I do smoke at least ONE JkY A WEEK.5. ( ) I smoke cigarettes just about every day, but less than half a pack a day.6. ( ) I smoke half a pack or more of cigarettes just about every day.

B. AT WHAT AGE DID YOU SMOKE YOUR FIRST CIGARE1TE: Age__ Never Smoked_

C. DO YOUR PARENTS SMOKE? (Check one)

Father only Mother only Both Parents Neither Parent

P. Check YES or NO on the following questions.

1. Do you approve of boys smoking? yes no2. Do you approve of girls smoking? yes no3. Do you smoke in mixed company? yes_ no4. Do you smoke in front of your parents? yes_ no

E. HOW DO YOUR PARENTS FEEL ABOUT YOUR SMOKING? (If you don't smoke, how would theyfeel if you did smoke?) (Check one)

Mother Father1. Approve. All right.2. They are against it.3. They would not allow me to smoke.4. They don't care.S. I don't know.

F. I DON'T SMOKE BECAUSE: (Check one)

1. ( ) It will harm my health. S. ( ) I don't get any enjoyment out2. ( ) I don't want to get the habit. of it.3. ( ) It doesn't look good. 6. ( ) It's a challenge to show others4. ( ) -It's too expensive. I don't.

G. I SMOKE BECAUSE: (Check one)

1. ( ) iI enjoy it. S. ( ) It helps me feel grown up.2. ( ) Smoking relaxes me. 6. ( ) It helps me defy or disobey Adults.3. ( ) It has become a habit. 7. ( ) It helps me show off.4. ( ) I want to be part of the crowd.

H. OTHER YOUNG PEOPLE SMOKE BECAUSE: (Check one)

1. ( ) They enjoy it. S. ( ) It helps them feel grown up.2. ( ) Smoking relaxes them. 6. ( ) It helps them defy or disobey3. ( ) It has become a habit. Adults.4. ( ) They want to be part of the crowd. 7. ( ) It helps them show off.

I. AT THE PRESENT TIME: I SMOKE I DO NOT 9MOKE_

J. I Do DO NOT believe that cigarette smoking causes lung cancer, heart disease,and other chest diseases.


APPENDIX A-Continued

K. I COULD COULD NOT_ be persuaded to give up smoking.

RADIO AND TV PROGRAMS AND COIMNCIALS HAVE INFLUENCED MT IDEAS ABOUT SMOKING.

Yess No_

If answer Es yes, check belnw

Ihey have influencedl me in favor of smoking.

They have influenced me against smoking.

A PROJECT OFTHE NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM

4/19/71

CELL CULTURE CENTER

A remodeled candy factory in Cambridge, Massachusetts, now houses a production facility runby men and women in white laboratory coats.

Instead of producing chocolates, they're growing cells and viruses-millions, even billions ofthem-in rows of bottles filled with sterile solutions consisting of various salts, water, nutrients, andblood serum.

This precious harvest goes to researchers throughout the northeastern United States who lackfacilities to grow the large quantities of cells and viruses they need for studies in basic cell biology.

The Cell Culture Center at the Massachusetts Institute of Technology, established and funded bythe National Science Foundation, is one of two such facilities in the United States. (The second, atthe University of Alabama, will be in operation in the near future.)

The Center is headed by Dr. P. W. Robbins, professor of biochemistry in the MIT Department ofBiology, and Dr. Richard L. Davidson of the Harvard Medical School, and is operated under thedirection of Mr. Don Giard. It is located in the Seeley G. Mudd Building at 40 Ames St., a formercandy factory, which also houses the Arteriosclerosis Center and the MIT Center for Cancer Research.


The Growing Epidemic

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